Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Sep 2020
ReviewThe Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction.
Ischemic heart disease, the leading cause of death worldwide, may result in devastating perioperative ischemia and infarction. The underlying pathophysiology, precipitating factors, and approach to prevention differ between patients presenting for noncardiac surgery, developing acute coronary syndrome versus stable angina. The first half of this article reviews the pathophysiology of acute coronary syndrome and stable angina. ⋯ After this discussion, the review article considers how both apply to perioperative myocardial infarctions and myocardial injury after noncardiac surgery. This article furthermore argues why myocardial oxygen delivery demand mismatch (Type 2) myocardial infarction is the most likely underlying pathophysiology responsible for perioperative myocardial infarctions. Being aware of this and knowledgeable about Type 2 infarctions may enable anesthetic providers to better predict the majority of triggers contributing to, and thus decreasing the incidence of, perioperative myocardial infarctions.
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J. Cardiothorac. Vasc. Anesth. · Sep 2020
ReviewChronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes.
Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. ⋯ Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.
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J. Cardiothorac. Vasc. Anesth. · Sep 2020
ReviewExpert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist.
Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. ⋯ The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.
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J. Cardiothorac. Vasc. Anesth. · Sep 2020
Risk Factors for Emergence Agitation in Adults Undergoing Thoracoscopic Lung Surgery: A Case-Control Study of 1,950 Patients.
The present study investigated the incidence of and risk factors for emergence agitation (EA) in adult patients after thoracoscopic lung surgery. ⋯ EA is a common complication after thoracoscopic lung surgery, especially within a certain population. Adequate perioperative management, which comprises wound infiltration, the maintenance of intraoperative hemodynamic stability, sufficient analgesia, and the use of dexmedetomidine, should be adopted to reduce the incidence of EA.
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J. Cardiothorac. Vasc. Anesth. · Sep 2020
The Prevalence and Impact of Undiagnosed Mild Cognitive Impairment in Elderly Patients Undergoing Thoracic Surgery: A Prospective Cohort Study.
The objective of this study was to explore the prevalence of undiagnosed mild cognitive impairment (MCI) and its association with adverse outcomes in elderly patients undergoing thoracic surgery. ⋯ The incidence of MCI before thoracic surgery in elderly patients was higher and associated with a higher rate of adverse postoperative outcomes. The findings may be important for preoperative patient counseling, operative planning, and eventually reducing potential risk exposure and related outcomes.